Chief Complaint Identifying Data • • • • Age: Sex: Race: Occupation: Contributory Medical or Dental History (Ignore if normal) • Medical diagnosis and history • Medications • Previous orthodontics, splints, surgery, etc. Temporomandibular Disorder (Ignore if normal) Clinical Diagnostic Exam • Dental: • Periodontal: • Neurologic, Muscular, Orthopedic, Neurovascular: • Occlusal Analysis: Pre-treatment Facial slides Frontal Frontal/Smiling Pre-treatment Facial slides Right 45゜ Right Profile Pre-treatment X-Rays Cephalometric Film Frontal Lateral Pre-treatment X-Rays Panoramic Film or Full Mouth X-Rays Pre-treatment X-Rays Wrist Film (Growing Patients) Pre-treatment X-Rays SMV Pre-treatment TMJ X-Rays Axis Oriented Tomograms or CBCT Pre-treatment Intraoral Slides Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal Pre-treatment Mounted Models Right Buccal Frontal Left Buccal Right Overjet CPI Left Overjet Pre-treatment CPI or MPI Pre-treatment Axiograph or Axi-path CO-CR Conversion • Tracing CO in Black • Tracing CR in Purple Pre-treatment Ricketts CR Pre-treatment Roth-Jarabak CR Reason of splint therapy Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Overjet Left Buccal Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Overjet Left Buccal Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Overjet Left Buccal Splint Therapy Progress Slides 00 Weeks Later Right Buccal Frontal Overjet Left Buccal CPI Data Sheet Summary Changes in CPI data during splint therapy Left Right Initial 00 weeks 00 weeks 00 weeks 00 weeks 00 weeks 00 weeks 00 weeks L R Post Splint Facial slides Frontal Frontal/Smiling Post Splint Facial slides Right 45゜ Right Profile Post Splint X-Rays Cephalometric Film Frontal Lateral Post Splint TMJ X-Rays Axis Oriented Tomograms or CBCT Post Splint Intraoral Slides Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal Post Splint Mounted Models Right Buccal Right Overjet Frontal Left Buccal Left Overjet Post Splint Split Cast Check Post Splint Ricketts CR Post Splint Roth-Jarabak CR Pre Splint VS Post Splint Full Superimposition • Tracing Pre Splint in Black • Tracing Post Splint in Green Pre Splint VS Post Splint 5 Point Superimposition • Tracing Pre Splint in Black • Tracing Post Splint in Green Post Splint Axiograph or Axi-path Post Splint Mounted Models 3-D Check Right Buccal Right Overjet Frontal Left Buccal Left Overjet Problem List After Splint Therapy Treatment Plan Mechanics Post Splint VS VTO Full Superimposition • Tracing Post Splint in Green • Tracing VTO in Red Post Splint VS VTO 5 Point Superimposition • Tracing Post Splint in Green • Tracing VTO in Red Post Splint VS VTO Image Treatment Progress Intraoral Slides Wire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later Treatment Progress Intraoral Slides Wire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later Treatment Progress Intraoral Slides Wire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later Treatment Progress Intraoral Slides Wire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later Treatment Progress Intraoral Slides Wire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later Treatment Progress Intraoral Slides Wire sequence Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal 00 months Later End of fixed type appliance therapy Mounted Models Right Buccal Frontal Left Buccal Right Overjet CPI Left Overjet End of fixed type appliance therapy Axi-path or Axiograph Gnathological Positioner Set-up Right Buccal Right Overjet Frontal Left Buccal Left Overjet Post-treatment Intraoral Slides Right Buccal Frontal Left Buccal Upper Occlusal Overjet Lower Occlusal Post-treatment Mounted Models Right Buccal Frontal Left Buccal Right Overjet CPI Left Overjet Post-treatment CPI or MPI Post-treatment Facial slides Frontal Frontal/Smiling Post-treatment Facial slides Right 45゜ Right Profile Post-treatment X-Rays Cephalometric Film Frontal Lateral Post-treatment X-Rays Panoramic Film or Full Mouth X-Rays Post-treatment TMJ X-Rays Axis Oriented Tomograms or CBCT Post-treatment Ricketts Post-treatment Roth-Jarabak Post Splint VS Post Tx Full Superimposition • Tracing Post Splint in Green • Tracing Post Ontho. in Blue Post Splint VS Post Tx 5 Point Superimposition • Tracing Post Splint in Green • Tracing Post Ontho. in Blue VTO VS Post Tx Full Superimposition • Tracing VTO in Red • Tracing Post Ortho. in Blue VTO VS Post Tx 5 Point Superimposition • Tracing VTO in Red • Tracing Post Ortho. in Blue
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